HSVI Registry Data dictionary

2021

Head, Spinal Cord and Violent Injury

(HSVI) Registry Data Dictionary

2021

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Mandatory Data Fields titled in Blue font Illinois Specific Data Fields titled in Purple font Optional Data Fields titled in Black font Italics font indicates a notation or user tip “?” = Not Known/Not Recorded “/” = N/A or Not Applicable

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Section: Creating New Record - HSVI

To Start a New Record – Select “Add New”

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Section: New Record/Arrival Date - HSVI

ARRIVAL DATE Definition The patient’s arrival date to the facility. This is also the ED/HOSPITAL ARRIVAL DATE which is the date the patient arrived to the ED/hospital. Click on “Save” once Arrival Date is entered. Element Values • Relevant value for data element Additional Information • If the patient was brought to the ED, report date patient arrived at ED. If patient was directly admitted to the hospital, report date patient was admitted to the hospital. • Reported as MM-DD-YYYY. Data Source Hierarchy Guide 1. Triage 4. Billing Sheet 2. ED Record 5. Discharge Summary 3. Face Sheet Associated Edit Checks Rule ID Level Message 4501 1 Date is not valid 4502 1 Date out of range 4503 2 Element cannot be blank 4505 2 Element cannot be “Not Known/Not Recorded” 4506 3 ED/Hospital Arrival Date is earlier than EMS Dispatch Date 4507 3 ED/Hospital Arrival Date is earlier than EMS Unit Arrival on Scene Date 4508 3 ED/Hospital Arrival Date is earlier than EMS Unit Scene Departure Date 4509 2 ED/Hospital Arrival Date is later than ED Discharge Date 4510 2 ED/Hospital Arrival Date is later than Hospital Discharge Date 4511 2 ED/Hospital Arrival Date is earlier than Date of Birth 4513 3 ED/Hospital Arrival Date minus Injury Incident Date is more than 14 days 4515 2 Element cannot be “Not Applicable” 4540 1 Single Entry Max exceeded

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Section: Demographic/Record Information

Parts of the Record Information section are auto populated. 1. Record Information Tab: The “Record Created Date and Time” will auto populate 2. Record Information Tab: The “Record Created By” will auto populate to user logged in and creating the chart 3. Record Information Tab: The facility name and number will auto populate Initial Location Place where the patient was initially treated upon arrival to the facility. Element Values: DI Dropdown Menu 1. Resuscitation room 8. Observation Unit 2. Emergency Department 9. Burn Unit 3. Operating Room 10. This number missing an element 4. Intensive Care Unit 11. Post Anesthesia Care Unit 5. Step-Down Unit 12. Special Procedure Unit 6. Floor 13. Labor and Delivery 7. Telemetry Unit ?. Unknown Data Source Hierarchy Guide 1. ADT Events 2. Encounter Report (EMR) 3. Nursing Notes 4. Triage – Arrival information 5. H&P

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Section: Demographic/Record Information

PATIENT TYPE Choose Patient Type 2, HSVI from Patient Type Dropdown Menu

Parts of the Identifiers section are autopopulated:

• Identifiers Tab: The “Trauma#” when record was created will auto populate

• Identifiers Tab: The “Patient Arrival Date” will auto populate based on the saved Arrival Date when the record was created

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Section: Demographic/Record Info

• Inclusion Information Tab Defaults to “N” for NTDB and “Y” for State. Leave as is.

• Select “HSVI” tab

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Section: HSVI/Demographic/Record Information/Arrival Time

PATIENT ARRIVAL TIME The patient’s arrival time to the facility. This is also the ED/HOSPITAL ARRIVAL TIME Definition The time the patient arrived to the ED/hospital. Element Values • Relevant value for data element Additional Information • If the patient was brought to the ED, report time patient arrived at ED. If patient was directly admitted to the hospital, report time patient was admitted to the hospital. • Reported as HH:MM military time. Data Source Hierarchy Guide 1. Triage/Trauma Flow Sheet 4. Billing Sheet 2. ED Record 5. Discharge Summary 3. Face Sheet Associated Edit Checks Rule ID Level Message 4601 1 Time is not valid 4602 1 Time out of range 4603 2 Element cannot be blank 4604 3 ED/Hospital Arrival Time is earlier than EMS Dispatch Time 4605 3 ED/Hospital Arrival Time is earlier than EMS Unit Arrival on Scene Time 4606 3 ED/Hospital Arrival Time is earlier than EMS Unit Scene Departure Time 4607 3 ED/Hospital Arrival Time is later than ED Discharge Time 4608 2 ED/Hospital Arrival Time is later than Hospital Discharge Time 4609 2 Element cannot be “Not Applicable” 4640 1 Single Entry Max exceeded

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Section: HSVI/Demographic/Record Information/Medical Record Number

MEDICAL RECORD NUMBER Definition Number assigned to patient (MRN): Every patient’s number is unique to them and is the same for every visit. Element Values • Relevant value for data element Data Source Hierarchy Guide: 1. Face Sheet 2. EMR Banner

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Section: HSVI/Demographic/Record Information/Account Number

ACCOUNT NUMBER Definition Patient number assigned for that specific encounter: primarily used for billing and coding. Element Values Relevant Value for Data Element Data Source Hierarchy Guide 1. Face Sheet

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Section: HSVI/Demographic/Record Information/Patient Last, First Name

PATIENT NAME Definition Patient’s legal name. Element Values • Relevant value for data element Data Source Hierarchy Guide 1. Face Sheet 2. Snapshot – Demographics 3. EMR Patient Banner

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Section: HSVI/Demographic/Patient/Date of Birth

DATE OF BIRTH Definition The patient's date of birth. Element Values • Relevant value for data element Additional Information • Reported as MM-DD-YYYY. • If Date of Birth is “Not Known/Not Recorded,” report data elements: Age and Age Units. • If Date of Birth is the same as the Injury Incident Date, then the Age and Age Units data elements must be reported. Data Source Hierarchy Guide 1. Face Sheet 2. Billing Sheet 3. Admission Form 4. Triage/Trauma Flow Sheet 5. EMS Run Report Associated Edit Checks Rule ID Level Message 0601 1 Invalid value 0602 1 Date out of range 0603 2 Element cannot be blank 0609 2 Date of Birth is later than Injury Incident Date

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Section: HSVI/Demographic/Patient/Date of Birth 0610 2 Date of Birth is later than ED Discharge Date 0611 2 Date of Birth is later than Hospital Discharge Date 0612 2 Date of Birth + 120 years must be less than Injury Incident Date 0613 2 Element cannot be “Not Applicable” 0640 1 Single Entry Max exceeded

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Section: HSVI/Demographic/Patient/Age Units

AGE UNITS Definition The units used to report the patient's age (Minutes, Hours, Days, Months, Years, Weeks). Element Values 1. Hours 4. Years 2. Days 5. Minutes 3. Months 6. Weeks Additional Information • If Date of Birth is “Not Known/Not Recorded,” report data elements: Age and Age Units. • If Date of Birth is the same as the ED/Hospital Arrival Date, then the Age and Age Units data elements must be reported. • Must also report data element: Age. • The null value “Not Applicable” is reported if Date of Birth is reported. Data Source Hierarchy Guide 1. Face Sheet 2. Billing Sheet 3. Admission Form 4. Triage/Trauma Flow Sheet 5. EMS Run Report Associated Edit Checks Rule ID Level Message 0801 1 Value is not a valid menu option 0803 2 Element cannot be blank

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Section: HSVI/Demographic/Patient/Age Units 0806 2 Element must be “Not Known/Not Recorded” when Age is “Not Known/Not Recorded” 0809 2 Element must be “Not Applicable” when Date of Birth is reported 0840 1 Single Entry Max exceeded Age auto calculates based on patient’s date of birth

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Section: HSVI/Demographic/Patient/Race

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Section: HSVI/Demographic/Patient/Race RACE Definition The patient's race. Element Values 1. American Indian 2. Asian 3. Black or African American 4. Native Hawaiian or Other Pacific Islander 5. White 6. Other Race ?. Unknown Additional Information • Patient race should be based upon self-report or identified by a family member. • Based on the 2010 US Census Bureau. • Report all that apply. Data Source Hierarchy Guide 1. Face Sheet 2. Billing Sheet 3. Admission Form 4. Triage/Trauma Flow Sheet 5. EMS Run Report 6. History & Physical Associated Edit Checks Rule ID Level Message 0901 1 Value is not a valid menu option 0902 2 Element cannot be blank 0903 2 Element cannot be “Not Applicable” (excluding CA hospitals) 0905 2 If any Element Value is reported, neither “Not Applicable” or “Not Known/Not Recorded” can also be reported 0950 1 Multiple Entry Max exceeded

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Section: HSVI/Demographic/Patient/Gender

SEX Definition The patient's sex. Element Values 1. Male 2. Female 3. Non-Binary (screenshot not current) Additional Information • Patients who have undergone a surgical and/or hormonal sex reassignment should be reported using their current assignment. Data Source Hierarchy Guide 1. Face Sheet 2. Billing Sheet 3. Admission Form 4. Triage/Trauma Flow Sheet 5. EMS Run Report 6. History & Physical Associated Edit Checks Rule ID Level Message 1101 1 Value is not a valid menu option 1102 2 Element cannot be blank 1103 2 Element cannot be “Not Applicable” 1140 1 Single Entry Max exceeded

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Section: HSVI/Demographic/Patient/Ethnicity

ETHNICITY Definition The patient's ethnicity. Element Values 1. Hispanic or Latino 2. Not Hispanic or Latino ?. Unknown Additional Information • Patient ethnicity should be based upon self-report or identified by a family member. • The maximum number of ethnicities that may be reported for an individual patient is 1. • Based on the 2010 US Census Bureau. Data Source Hierarchy Guide 1. Face Sheet 2. Billing Sheet 3. Admission Form 4. Triage/Trauma Flow Sheet 5. History & Physical 6. EMS Run Report Associated Edit Checks Rule ID Level Message 1001 1 Value is not a valid menu option 1002 2 Element cannot be blank 1003 2 Element cannot be “Not Applicable” (excluding CA hospitals) 1040 1 Single Entry Max exceeded

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Section: HSVI/Demographic/Patient/ZIP – Postal Code

PATIENT'S HOME ZIP/POSTAL CODE Definition The patient's home ZIP/Postal code of primary residence. Element Values • Relevant value for data element Additional Information • Can be stored as a 5 or 9-digit code (XXXXX-XXXX) for US or can be stored in the postal code format of the applicable country. • May require adherence to HIPAA regulations. • If ZIP/Postal code is "Not Applicable," report data element: Alternate Home Residence. • If ZIP/Postal code is "Not Known/Not Recorded," report data elements: Patient's Home Country, Patient's Home State (US only), Patient's Home County (US only) and Patient's Home City (US only). • If ZIP/Postal code is reported, must also report Patient's Home Country. Data Source Hierarchy Guide 1. Face Sheet 2. Billing Sheet 3. Admission Form Associated Edit Checks Rule ID Level Message 0001 1 Invalid value 0002 2 Element cannot be blank 0040 1 Single Entry Max exceeded

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Section: HSVI/Demographic/Patient/Street Address/Homeless

PATIENT: HOMELESS Definition A person who lacks housing. The definition also includes a person living in transitional housing or a supervised public or private facility providing temporary living quarters Element Values Y. Yes N. No NA. Not Applicable UKN. Unknown Data Source Hierarchy Guide 1. Face Sheet 2. Billing Sheet 3. Admission form 4. EMS Run Sheet Note: Homeless field is only active if Zip Code is “/ - Not Applicable” Note: If Zip Code is “/ - Not Applicable,” the “Alternate Residence” field becomes active

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Section: HSVI/Demographic/Patient/Street Address

PATIENT ADDRESS - STREET 1, STREET 2 Definition Address where the patient currently resides. Street 2 is used for apartment numbers and PO Boxes Element Values • Relevant value for data element Data Source Hierarchy Guide 1. Face Sheet 2. Snapshot – Demographic information 3. EMS Run Sheet

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Section: HSVI/Demographic/Patient/Home City

PATIENT'S HOME CITY Definition The patient's city (or township, or village) of residence. Element Values • Relevant value for data element (five-digit numeric FIPS code) Additional Information • Only reported when ZIP/Postal code is "Not Known/Not Recorded" and country is US. • Used to calculate FIPS code. • The null value "Not Applicable" is reported if Patient's Home ZIP/Postal Code is reported. • The null value “Not Applicable” is reported for non-US hospitals Data Source Hierarchy Guide 1. Face Sheet 2. Billing Sheet 3. Admission Form Associated Edit Checks Rule ID Level Message 0401 1 Invalid value 0402 2 Element cannot be blank 0404 2 Element must be “Not Applicable” (Non-US hospitals only) 0405 2 Element must be “Not Applicable” when Patient’s Home Zip/Postal Code is reported 0440 1 Single Entry Max exceeded May auto populate based upon ZIP Code

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Section: HSVI/Demographic/Patient/Home State

PATIENT'S HOME STATE Definition The state (territory, province, or District of Columbia) where the patient resides. Element Values • Relevant value for data element (two-digit numeric FIPS code) Additional Information • Only reported when ZIP/Postal code is "Not Known/Not Recorded" and country is US. • Used to calculate FIPS code. • The null value "Not Applicable" is reported if Patient's Home ZIP/Postal Code is reported. • The null value “Not Applicable” is reported for non-US hospitals. Data Source Hierarchy Guide 1. Face Sheet 2. Billing Sheet 3. Admission Form Associated Edit Checks Rule ID Level Message 0201 1 Invalid value 0202 2 Element cannot be blank 0204 2 Element must be “Not Applicable” (Non-US hospitals only) 0205 2 Element must be “Not Applicable” when Patient’s Home Zip/Postal code is reported 0240 1 Single Entry Max exceeded May auto populate based upon ZIP Code

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Section: HSVI/Demographic/Patient/Home County

PATIENT'S HOME COUNTY Definition The patient's county (or parish) of residence. Element Values • Relevant value for data element (three-digit numeric FIPS code) Additional Information • Only reported when ZIP/Postal code is "Not Known/Not Recorded" and country is US. • Used to calculate FIPS code. • The null value "Not Applicable" is reported if Patient's Home ZIP/Postal Code is reported. • The null value “Not Applicable” is reported for non-US hospitals. Data Source Hierarchy Guide 1. Face Sheet 2. Billing Sheet 3. Admission Form Associated Edit Checks Rule ID Level Message 0301 1 Invalid value 0302 2 Element cannot be blank 0304 2 Element must be “Not Applicable” (Non-US hospitals only) 0305 2 Element must be “Not Applicable” when Patient’s Home Zip/Postal Code is reported 0340 1 Single Entry Max exceeded May auto populate based upon ZIP Code

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Section: HSVI/Demographic/Patient/Home Country

PATIENT'S HOME COUNTRY Definition The country where the patient resides. Element Values • Relevant value for data element (two-digit alpha country code) Additional Information • Values are two-character FIPS codes representing the country (e.g., US). • If Patient's Home Country is not US, then the null value "Not Applicable" is reported for: Patient's Home State, Patient's Home County, and Patient's Home City. Data Source Hierarchy Guide 1. Face Sheet 2. Billing Sheet 3. Admission Form Associated Edit Checks Rule ID Level Message 0101 1 Invalid value 0102 2 Element cannot be blank 0104 2 Element cannot be “Not Applicable” 0105 2 Element cannot be "Not Known/Not Recorded" when Home ZIP/Postal Code is not "Not Applicable" or "Not Known/Not Recorded" 0140 1 Single Entry Max exceeded

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Section: HSVI/Demographic/Patient/Alternate Residence

ALTERNATE HOME RESIDENCE PATIENT: ALTERNATE HOME RESIDENCE Definition Documentation of the type of patient without a home ZIP/Postal Code. Element Values 1. Undocumented Citizen 2. Migrant Worker 3. Foreign Visitor /. Not Applicable ?. Unknown Additional Information

• Only reported when ZIP/Postal code is "Not Applicable."

• Homeless is defined as a person who lacks housing. The definition also includes a person living in transitional housing or a supervised public or private facility providing temporary living quarters.

• Undocumented Citizen is defined as a national of another country who has entered or stayed in another country without permission.

• Migrant Worker is defined as a person who temporarily leaves his/her principal place of residence within a country in order to accept seasonal employment in the same or different country.

• The null value "Not Applicable" is reported if Patient's Home ZIP/Postal Code is reported.

• Report all that apply

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Section: HSVI/Demographic/Patient/Alternate Residence Data Source Hierarchy Guide 1. Face Sheet 2. Billing Sheet 3. Admission Form 4. EMS Run Sheet 5. Case Management/Social Services notes 6. H & P 7. Progress Notes Associated Edit Checks Rule ID Level Message 0501 1 Value is not a valid menu option 0502 2 Element cannot be blank 0503 2 Element cannot be “Not Applicable” or “Not Known/Not Recorded” along with any other valid value 0540 1 Multiple Entry Max exceeded Note: Alternate Residence field is only active if “/ - Not Applicable” is selected for Home Zip Code.

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Section: HSVI/Demographic/Patient/Telephone

Telephone Definition A form of communication using a ten (10) digit number where a patient can be contacted.

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Section: HSVI/Injury/Injury Information/Injury Date

INJURY INCIDENT DATE Definition The date the injury occurred. Element Values • Relevant value for data element Additional Information • Reported as MM-DD-YYYY. • Estimates of date of injury should be based upon report by patient, witness, family, or healthcare provider. Other proxy measures (e.g., 911 call times) should not be reported. Data Source Hierarchy Guide 1. EMS Run Report 2. Triage/Trauma Flow Sheet 3. History & Physical 4. Face Sheet Associated Edit Checks Rule ID Level Message 1201 1 Date is not valid 1202 1 Date out of range 1203 2 Element cannot be blank 1204 2 Injury Incident Date is earlier than Date of Birth 1205 3 Injury Incident Date is later than EMS Dispatch Date 1206 3 Injury Incident Date is later than EMS Unit Arrival on Scene Date 1207 3 Injury Incident Date is later than EMS Unit Scene Departure Date

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Section: HSVI/Injury/Injury Information/Injury Date 1208 3 Injury Incident Date is later than ED/Hospital Arrival Date 1209 3 Injury Incident Date is later than ED Discharge Date 1210 2 Injury Incident Date is later than Hospital Discharge Date 1211 2 Element cannot be “Not Applicable” 1212 3 Injury Incident Date is greater than 14 days earlier than ED/Hospital Arrival Date 1240 1 Single Entry Max exceeded

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Section: HSVI/Injury/Injury Information/Injury Time

INJURY INCIDENT TIME Definition The time the injury occurred. Element Values • Relevant value for data element Additional Information • Reported as HH:MM military time. • Estimates of time of injury should be based upon report by patient, witness, family, or health care provider. Other proxy measures (e.g., 911 call times) should not be reported. Data Source Hierarchy Guide 1. EMS Run Report 2. Triage/Trauma Flow Sheet 3. History & Physical 4. Face Sheet Associated Edit Checks Rule ID Level Message 1301 1 Time is not valid 1302 1 Time out of range 1303 2 Element cannot be blank 1304 3 Injury Incident Time is later than EMS Dispatch Time 1305 3 Injury Incident Time is later than EMS Unit Arrival on Scene Time 1306 3 Injury Incident Time is later than EMS Unit Scene Departure Time 1307 3 Injury Incident Time is later than ED/Hospital Arrival Time

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Section: HSVI/Injury/Injury Information/Injury Date 1308 3 Injury Incident Time is later than ED Discharge Time 1309 2 Injury Incident Time is later than Hospital Discharge Time 1310 2 Element cannot be “Not Applicable” 1340 1 Single Entry Max exceeded

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Section: HSVI/Injury/Injury Information/ICD 10 Injury Location

ICD-10 PLACE OF OCCURRENCE EXTERNAL CAUSE CODE Definition Place of occurrence external cause code used to describe the place/site/location of the injury event (Y92.X). Element Values • Relevant ICD-10-CM code value for injury event Additional Information • Only ICD-10-CM codes are accepted for ICD-10 Place of Occurrence External Cause Code. Data Source Hierarchy Guide 1. EMS Run Report 2. Triage/Trauma Flow Sheet 3. Nursing Notes/Flow Sheet 4. History & Physical 5. Progress Notes Associated Edit Checks Rule ID Level Message 9001 1 Invalid value (ICD-10-CM only) 9002 2 Element cannot be blank 9003 3 Place of Injury code should be Y92.X/Y92.XX/Y92.XXX (where X is A-Z [excluding I,O] or 0-9) (ICD-10-CM only) 9004 1 Invalid value (ICD-10-CA only) 9005 3 Place of Injury code should be U98X (where X is 0-9) (ICD-10-CA only) 9006 2 Element cannot be “Not Applicable”

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Section: HSVI/Injury/Injury Information/Injury Incident ZIP

INCIDENT LOCATION ZIP/POSTAL CODE Definition The ZIP/Postal code of the incident location. Element Values • Relevant value for data element Additional Information • Can be stored as a 5 or 9-digit code (XXXXX-XXXX) for US and CA, or can be stored in the postal code format of the applicable country. • If "Not Known/Not Recorded," report data elements: Incident Country, Incident State (US Only), Incident County (US Only) and Incident City (US Only). • May require adherence to HIPAA regulations. • If ZIP/Postal code is reported, then must report Incident Country. Data Source Hierarchy Guide 1. EMS Run Report 2. Triage/Trauma Flow Sheet Associated Edit Checks Rule ID Level Message 2001 1 Invalid value 2002 2 Element cannot be blank 2006 2 Element cannot be “Not Applicable” 2040 1 Single Entry Max exceeded Select “Copy Patient Address” if injury occurred at patients address

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Section: HSVI/Injury/Injury Information/Injury Incident Street Address

INJURY: STREET 1, STREET 2 Definition Address where the injury occurred. Street 2 is used for apartment numbers and PO boxes. Element Values 1. Relevant value for data element Data Source Hierarchy Guide 1. EMS Run Sheet 2. ED Trauma Narrator Event Log

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Section: HSVI/Injury/Injury Information/Injury Incident City

INCIDENT CITY Definition The city or township where the patient was found or to which the unit responded. Element Values • Relevant value for data element (five-digit numeric FIPS code) Additional Information • Only reported when Incident Location ZIP/Postal Code is "Not Known/Not Recorded," and country is US. • Used to calculate FIPS code. • If incident location resides outside of formal city boundaries, report nearest city/town. • The null value "Not Applicable" is reported if Incident Location ZIP/Postal Code is reported. • If Incident Country is not US, report the null value "Not Applicable." Data Source Hierarchy Guide 1. EMS Run Report 2. Triage/Trauma Flow Sheet Associated Edit Checks Rule ID Level Message 2401 1 Invalid value 2403 2 Element cannot be blank 2404 2 Element must be “Not Applicable” (Non-US hospitals) 2405 2 Element must be “Not Applicable” when Incident Location Zip/Postal Code is reported 2440 1 Single Entry Max exceeded May auto populate based upon ZIP Code

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Section: HSVI/Injury/Injury Information/Injury Incident State

INCIDENT STATE Definition The state, territory, or province where the patient was found or to which the unit responded (or best approximation). Element Values • Relevant value for data element (two-digit numeric FIPS code) Additional Information • Only reported when Incident Location ZIP/Postal Code is "Not Known/Not Recorded," and country is US. • Used to calculate FIPS code. • The null value "Not Applicable" is reported if Incident Location ZIP/Postal Code is reported. • If Incident Country is not US, report the null value "Not Applicable." Data Source Hierarchy Guide 1. EMS Run Report 2. Triage/Trauma Flow Sheet Associated Edit Checks Rule ID Level Message 2201 1 Invalid value 2203 2 Element cannot be blank 2204 2 Element must be “Not Applicable” (Non-US hospitals) 2205 2 Element must be “Not Applicable” when Incident Location Zip/Postal Code is reported 2240 1 Single Entry Max exceeded May auto populate based upon ZIP Code

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Section: HSVI/Injury/Injury Information/Injury Incident County

INCIDENT COUNTY Definition The county or parish where the patient was found or to which the unit responded (or best approximation). Element Values • Relevant value for data element (three-digit numeric FIPS code) Additional Information • Only reported when Incident Location ZIP/Postal Code is "Not Known/Not Recorded," and country is US. • Used to calculate FIPS code. • The null value "Not Applicable" is reported if Incident Location ZIP/Postal Code is reported. • If Incident Country is not US, report the null value "Not Applicable." Data Source Hierarchy Guide 1. EMS Run Report 2. Triage/Trauma Flow Sheet Associated Edit Checks Rule ID Level Message 2301 1 Invalid value (US only) 2303 2 Element cannot be blank 2304 2 Element must be “Not Applicable” (Non-US hospitals) 2305 2 Element must be “Not Applicable” when Incident Location Zip/Postal code is reported 2340 1 Single Entry Max exceeded

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Section: HSVI/Injury/Injury Information/Injury Incident Country

INCIDENT COUNTRY Definition The country where the patient was found or to which the unit responded (or best approximation). Element Values • Relevant value for data element (two-digit alpha country code) Additional Information • Values are two-character FIPS codes representing the country (e.g., US). • If Incident Country is not US, then the null value "Not Applicable" is reported for: Incident State, Incident County, and Incident Home City. Data Source Hierarchy Guide 1. EMS Run Report 2. Triage/Trauma Flow Sheet Associated Edit Checks Rule ID Level Message 2101 1 Invalid value 2102 2 Element cannot be blank 2104 2 Element cannot be “Not Applicable” 2105 2 Element cannot be "Not Known/Not Recorded" when Incident Location ZIP/Postal Code is not "Not Known/Not Recorded" 2140 1 Single Entry Max exceeded

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Section: HSVI/Injury/Injury Information/Work Related

WORK-RELATED Definition Indication of whether the injury occurred during paid employment. Element Values Y = Yes N = No / = Not Applicable UKN = Unknown Additional Information • If work-related, two additional data elements must be reported: Patient's Occupational Industry and Patient's Occupation. Data Source Hierarchy Guide 1. EMS Run Report 2. Triage/Trauma Flow Sheet 3. History & Physical 4. Face Sheet 5. Billing Sheet Associated Edit Checks Rule ID Level Message 1401 1 Value is not a valid menu option 1402 2 Element cannot be blank 1407 2 Element cannot be “Not Applicable” 1440 1 Single Entry Max exceeded

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Section: HSVI/Injury/Mechanism of Injury/ICD 10 Codes

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Section: HSVI/Injury/Mechanism of Injury/ICD 10 Codes ICD-10 PRIMARY EXTERNAL CAUSE CODE Definition External cause code used to describe the mechanism (or external factor) that caused the injury event. Element Values • Relevant ICD-10-CM code value for injury event Additional Information • The primary external cause code should describe the main reason a patient is admitted to the hospital. • ICD-10-CM codes are accepted for this data element. Activity codes are not reported under the NTDS and should not be reported for this data element. • Multiple Cause Coding Hierarchy: If two or more events cause separate injuries, an external cause code should be reported for each cause. The first-listed external cause code will be selected in the following order:

• External cause codes for child and adult abuse take priority over all other external cause codes.

• External cause codes for terrorism events take priority over all other external cause codes except child and adult abuse.

• External cause codes for cataclysmic events take priority over all other external cause codes except child and adult abuse, and terrorism.

• External cause codes for transport accidents take priority over all other external cause codes except cataclysmic events, and child and adult abuse, and terrorism.

• The first listed external cause code should correspond to the cause of the most serious diagnosis due to an assault, accident or self-harm, following the order of hierarchy listed above.

Data Source Hierarchy Guide 1. EMS Run Report 2. Triage/Trauma Flow Sheet 3. Nursing Notes/Flow Sheet 4. History & Physical 5. Progress Notes Associated Edit Checks Rule ID Level Message 8901 1 E-Code is not a valid ICD-10-CM code (ICD-10-CM only) 8902 2 Element cannot be blank 8904 2 Should not be Y92.X/Y92.XX/Y92.XXX (where X is A-Z or 0-9) (ICD-10-CM only) 8905 3 ICD-10 External Cause Code should not be Y93.X/Y93.XX (where X is A-Z or 0-9) (ICD-10 CM only) 8906 1 E-Code is not a valid ICD-10-CA code (ICD-10-CA only) 8907 2 Element cannot be “Not Applicable” 8940 1 Single Entry Max exceeded

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Section: HSVI/Injury/Mechanism of Injury/ICD 10 Codes

ICD-10 PLACE OF OCCURRENCE EXTERNAL CAUSE CODE Definition Place of occurrence external cause code used to describe the place/site/location of the injury event (Y92.X). Element Values • Relevant ICD-10-CM code value for injury event Additional Information • Only ICD-10-CM codes are accepted for ICD-10 Place of Occurrence External Cause Code. Data Source Hierarchy Guide 1. EMS Run Report 4. History & Physical 2. Triage/Trauma Flow Sheet 5. Progress Notes 3. Nursing Notes/Flow Sheet Associated Edit Checks Rule ID Level Message 9001 1 Invalid value (ICD-10-CM only) 9002 2 Element cannot be blank 9003 3 Place of Injury code should be Y92.X/Y92.XX/Y92.XXX (where X is A-Z [excluding I,O] or 0-9) (ICD-10-CM only) 9004 1 Invalid value (ICD-10-CA only) 9005 3 Place of Injury code should be U98X (where X is 0-9) (ICD-10-CA only)

9006 2 Element cannot be “Not Applicable” 9040 1 Single Entry Max exceeded

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Section: HSVI/Prehospital Scene – Transport

Select the “Add” Button Note: While this tab is labeled “Prehospital Scene/Transport,” for patients that arrived by “Private Vehicle or Walk-in” select the “Add” button and select “4 - Private Vehicle or Walk-in” and then select “OK”

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Section: HSVI/Prehospital Scene – Transport/Mode

TRANSPORT MODE Definition The mode of transport delivering the patient to your hospital. Element Values 1. Ground Ambulance 6. Public Safety2. Helicopter Ambulance 7. Water Ambulance3. Fixed-wing Ambulance 8. Other4. Private Vehicle or Walk-in /. Not Applicable5. Police ?. UnknownAdditional InformationData Source Hierarchy Guide1. EMS Run Report2. Triage Notes3. Nursing NotesAssociated Edit ChecksRule ID Level Message3401 1 Value is not a valid menu option3402 2 Element cannot be blank3404 2 Element cannot be “Not Applicable”3440 1 Single Entry Max exceeded

*Note: Selecting "4 -Private Vehicle or Walk-in" will make the prehospital fields inactive

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Section: HSVI/Prehospital Scene – Transport/Mode

NOTE: If the patient is transported to the hospital per this agency then Transport Role corresponds to Transport Mode in the NTDS data dictionary. All others involved in the transport correspond to the NTDS data dictionary’s “Other Transport Mode.” If the agency does not transport the patient, please mark the agency as non-transport. OTHER TRANSPORT MODE Definition All other modes of transport used during patient care event (prior to arrival at your hospital), except the mode delivering the patient to the hospital. Element Values 1. Ground Ambulance 4. Private/Public Vehicle/Walk-in 2. Helicopter Ambulance 5. Police 3. Fixed-wing Ambulance 6. Other Additional Information • Include in "Other" unspecified modes of transport. • The null value "Not Applicable" is reported to indicate that a patient had a single mode of transport. • Report all that apply with a maximum of 5. Data Source Hierarchy Guide 1. EMS Run Report Associated Edit Checks Rule ID Level Message 3501 1 Value is not a valid menu option 3502 2 Element cannot be blank 3550 1 Multiple Entry Max exceeded

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Section: HSVI/Prehospital Scene – Transport/Agency

AGENCY Definition The prehospital agency that is responsible for some or all aspects of the patient’s care prior to arrival at the hospital. There may be multiple agencies added based on who has responded to the scene. Element Values • Relevant Value for Data Element Data Source Hierarchy Guide 1. EMS Run Report

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Section: HSVI/Prehospital Scene – Transport/Unit

UNIT Definition Call sign used by the specific unit responding to the scene. Element Values • Relevant Value for Data Element Data Source Hierarchy Guide 1. EMS Run Report

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Section: HSVI/Prehospital Scene – Transport/Transport Role

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Section: HSVI/Prehospital Scene – Transport/Transport Role NOTE: If the patient is transported to the hospital per this agency then Transport Role corresponds to Transport Mode in the NTDS data dictionary. All others involved in the transport correspond to the NTDS data dictionary’s “Other Transport Mode.” If the agency does not transport the patient, please mark the agency as non-transport OTHER TRANSPORT MODE Definition All other modes of transport used during patient care event (prior to arrival at your hospital), except the mode delivering the patient to the hospital. Element Values 1. Ground Ambulance 4. Private/Public Vehicle/Walk-in 2. Helicopter Ambulance 5. Police 3. Fixed-wing Ambulance 6. Other Additional Information • Include in "Other" unspecified modes of transport. • The null value "Not Applicable" is reported to indicate that a patient had a single mode of transport. • Report all that apply with a maximum of 5. Data Source Hierarchy Guide 1. EMS Run Report Associated Edit Checks Rule ID Level Message 3501 1 Value is not a valid menu option 3502 2 Element cannot be blank 3550 1 Multiple Entry Max exceeded

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Section: HSVI/Prehospital Scene – Transport/Care Level

CARE LEVEL Definition The highest level of care the agency is able to provide to the patient based on Illinois State EMS regulations. Element Values 1. Advanced Life Support 2. Basic Life Support /. Not Applicable ?. Unknown Data Source Hierarchy Guide 1. EMS Run Report

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Section: HSVI/Prehospital Scene – Transport/Scene EMS Report

SCENE EMS REPORT Definition The prehospital report and its level of completion/hospital’s access to the report. Element Values 1. Complete 2. Incomplete 3. Missing 4. Unreadable /. Not Applicable ?. Unknown Section Data Source Hierarchy Guide 1. EMS Run Report 2. Media or Scanned Documents

52

Section: HSVI/Prehospital Scene – Transport/PCR Number

PCR NUMBER Definition The unique number assigned to the patient and the EMS call by the EMS agency. Element Values • Relevant Value for Data Element Data Source Hierarchy Guide 1. EMS Run Report

53

Section: HSVI/Prehospital Scene – Transport/Call Received Date and Time

CALL RECEIVED DATE AND TIME Definition The date and time that the call was received by the dispatcher Data Elements • Relevant value for data element Data Source Hierarchy Guide 1. EMS Run Report

54

Section: HSVI/Prehospital Scene – Transport/Call Dispatch Date

EMS DISPATCH DATE Definition The date the unit transporting to your hospital was notified by dispatch. Element Values • Relevant value for data element Additional Information • Reported as MM-DD-YYYY. • For inter-facility transfer patients, this is the date on which the unit transporting the patient to your facility from the transferring facility was notified by dispatch or assigned to this transport. • For patients transported from the scene of injury to your hospital, this is the date on which the unit transporting the patient to your facility from the scene was dispatched. • The null value "Not Applicable" is reported for patients who were not transported by EMS. Data Source Hierarchy Guide 1. EMS Run Report Associated Edit Checks Rule ID Level Message 2801 1 Date is not valid 2802 1 Date out of range 2803 3 EMS Dispatch Date is earlier than Date of Birth 2804 3 EMS Dispatch Date is later than EMS Unit Arrival on Scene Date 2805 3 EMS Dispatch Date is later than EMS Unit Scene Departure Date 2806 3 EMS Dispatch Date is later than ED/Hospital Arrival Date 2807 3 EMS Dispatch Date is later than ED Discharge Date

55

Section: HSVI/Prehospital Scene – Transport/Call Dispatch Date 2808 3 EMS Dispatch Date is later than Hospital Discharge Date 2809 2 Element cannot be blank 2840 1 Single Entry Max exceeded

56

Section: HSVI/Prehospital Scene – Transport/Call Dispatch Time

EMS DISPATCH TIME Definition The time the unit transporting to your hospital was notified by dispatch. Element Values • Relevant value for data element Additional Information • Reported as HH:MM military time. • For inter-facility transfer patients, this is the time at which the unit transporting the patient to your facility from the transferring facility was notified by dispatch. • For patients transported from the scene of injury to your hospital, this is the time at which the unit transporting the patient to your facility from the scene was dispatched. • The null value "Not Applicable" is reported for patients who were not transported by EMS. Data Source Hierarchy Guide 1. EMS Run Report Associated Edit Checks Rule ID Level Message 2901 1 Time is not valid 2902 1 Time out of range 2903 3 EMS Dispatch Time is later than EMS Unit Arrival on Scene Time 2904 3 EMS Dispatch Time is later than EMS Unit Scene Departure Time 2905 3 EMS Dispatch Time is later than ED/Hospital Arrival Time 2906 3 EMS Dispatch Time is later than ED Discharge Time 2907 3 EMS Dispatch Time is later than Hospital Discharge Time

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Section: HSVI/Prehospital Scene – Transport/Call Dispatch Time 2908 2 Element cannot be blank 2940 1 Single Entry Max exceeded

58

Section: HSVI/Prehospital Scene – Transport/Unit Enroute Date and Time

EN-ROUTE DATE AND TIME Definition The date and time that unit was en-route to the scene. Date Elements • Relevant value for data element Data Source Hierarchy Guide 1. EMS Run Report

59

Section: HSVI/Prehospital Scene – Transport/Rendezvous

RENDEZVOUS PICKUP LOCATION Definition Will only populate if the patient was transported to a rendezvous point to be transported by a different agency. The location where the transporting agency intercepted the patient. Date Elements • Relevant value for data element Data Source Hierarchy Guide 1. EMS Run Report

60

Section: HSVI/Prehospital Scene – Transport/Scene Arrival Date

EMS UNIT ARRIVAL DATE AT SCENE OR TRANSFERRING FACILITY Definition The date the unit transporting to your hospital arrived on the scene/transferring facility. Element Values • Relevant value for data element Additional Information • Reported as MM-DD-YYYY. • For inter-facility transfer patients, this is the date on which the unit transporting the patient to your facility from the transferring facility arrived at the transferring facility (arrival is defined at date/time when the vehicle stopped moving). • For patients transported from the scene of injury to your hospital, this is the date on which the unit transporting the patient to your facility from the scene arrived at the scene (arrival is defined at date/time when the vehicle stopped moving). • The null value "Not Applicable" is reported for patients who were not transported by EMS. Data Source Hierarchy Guide 1. EMS Run Report Associated Edit Checks Rule ID Level Message 3001 1 Date is not valid 3002 1 Date out of range 3003 3 EMS Unit Arrival on Scene Date is earlier than Date of Birth 3004 3 EMS Unit Arrival on Scene Date is earlier than EMS Dispatch Date 3005 3 EMS Unit Arrival on Scene Date is later than EMS Unit Scene Departure Date

61

Section: HSVI/Prehospital Scene – Transport/Scene Arrival Time 3006 3 EMS Unit Arrival on Scene Date is later than ED/Hospital Arrival Date 3007 3 EMS Unit Arrival on Scene Date is later than ED Discharge Date 3008 3 EMS Unit Arrival on Scene Date is later than Hospital Discharge Date 3009 3 EMS Unit Arrival on Scene Date minus EMS Dispatch Date is greater than 7 days 3010 2 Element cannot be blank 3040 1 Single Entry Max exceeded

62

Section: HSVI/Prehospital Scene – Transport/Scene Arrival Time

EMS UNIT ARRIVAL TIME AT SCENE OR TRANSFERRING FACILITY Definition The time the unit transporting to your hospital arrived on the scene/transferring facility. Element Values • Relevant value for data element Additional Information • Reported as HH:MM military time. • For inter-facility transfer patients, this is the time at which the unit transporting the patient to your facility from the transferring facility arrived at the transferring facility (arrival is defined at date/time when the vehicle stopped moving). • For patients transported from the scene of injury to your hospital, this is the time at which the unit transporting the patient to your facility from the scene arrived at the scene (arrival is defined at date/time when the vehicle stopped moving). • The null value "Not Applicable" is reported for patients who were not transported by EMS. Data Source Hierarchy Guide 1. EMS Run Report Associated Edit Checks Rule ID Level Message 3101 1 Time is not valid 3102 1 Time out of range 3103 3 EMS Unit Arrival on Scene Time is earlier than EMS Dispatch Time 3104 3 EMS Unit Arrival on Scene Time is later than EMS Unit Scene Departure Time 3105 3 EMS Unit Arrival on Scene Time is later than ED/Hospital Arrival Time

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Section: HSVI/Prehospital Scene – Transport/Scene Arrival Time 3106 3 EMS Unit Arrival on Scene Time is later than ED Discharge Time 3107 3 EMS Unit Arrival on Scene Time is later than Hospital Discharge Time 3108 2 Element cannot be blank 3140 1 Single Entry Max exceeded

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Section: HSVI/Prehospital Scene – Transport/Arrived at Patient Date and Time

ARRIVED AT PATIENT DATE AND TIME Definition The date and time that the prehospital personnel made contact with the patient. Date Elements • Relevant value for data element Data Source Hierarchy Guide 1. EMS Run Report

65

Section: HSVI/Prehospital Scene – Transport/Departed Scene Date

EMS UNIT DEPARTURE DATE FROM SCENE OR TRANSFERRING FACILITY Definition The date the unit transporting to your hospital left the scene/transferring facility. Element Values • Relevant value for data element Additional Information • Reported as MM-DD-YYYY. • For inter-facility transfer patients, this is the date on which the unit transporting the patient to your facility from the transferring facility departed from the transferring facility (departure is defined at date/time when the vehicle started moving). • For patients transported from the scene of injury to your hospital, this is the date on which the unit transporting the patient to your facility from the scene departed from the scene (departure is defined at date/time when the vehicle started moving). • The null value "Not Applicable" is reported for patients who were not transported by EMS. Data Source Hierarchy Guide 1. EMS Run Report Associated Edit Checks Rule ID Level Message 3201 1 Date is not valid 3202 1 Date out of range 3203 3 EMS Unit Scene Departure Date is earlier than Date of Birth 3204 3 EMS Unit Scene Departure Date is earlier than EMS Dispatch Date 3205 3 EMS Unit Scene Departure Date is earlier than EMS Unit Arrival on Scene Date

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Section: HSVI/Prehospital Scene – Transport/Departed Scene Date 3206 3 EMS Unit Scene Departure Date is later than ED/Hospital Arrival Date 3207 3 EMS Unit Scene Departure Date is later than ED Discharge Date 3208 3 EMS Unit Scene Departure Date is later than Hospital Discharge Date 3209 3 EMS Unit Scene Departure Date minus EMS Unit Arrival on Scene Date is greater than 7 days 3210 2 Element cannot be blank 3240 1 Single Entry Max exceeded

67

Section: HSVI/Prehospital Scene – Transport/Departed Scene Time

EMS UNIT DEPARTURE TIME FROM SCENE OR TRANSFERRING FACILITY Definition The time the unit transporting to your hospital left the scene/transferring facility. Element Values • Relevant value for data element Additional Information • Reported as HH:MM military time. • For inter-facility transfer patients, this is the time at which the unit transporting the patient to your facility from the transferring facility departed from the transferring facility (departure is defined at date/time when the vehicle started moving). • For patients transported from the scene of injury to your hospital, this is the time at which the unit transporting the patient to your facility from the scene departed from the scene (departure is defined at date/time when the vehicle started moving). • The null value "Not Applicable" is reported for patients who were not transported by EMS. Data Source Hierarchy Guide 1. EMS Run Report Associated Edit Checks Rule ID Level Message 3301 1 Time is not valid 3302 1 Time out of range 3303 3 EMS Unit Scene Departure Time is earlier than EMS Dispatch Time 3304 3 EMS Unit Scene Departure Time is earlier than EMS Unit Arrival on Scene Time 3305 3 EMS Unit Scene Departure Time is later than ED/Hospital Arrival Time

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Section: HSVI/Prehospital Scene – Transport/Departed Scene Time 3306 3 EMS Unit Scene Departure Time is later than the ED Discharge Time 3307 3 EMS Unit Scene Departure Time is later than Hospital Discharge Time 3308 2 Element cannot be blank 3340 1 Single Entry Max exceeded

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Section: HSVI/Prehospital Scene – Transport/Arrived Destination Date and Time

ARRIVED AT DESTINATION DATE AND TIME Definition The date and time that the transporting unit arrived to the hospital. Date Elements • Relevant value for data element Data Source Hierarchy Guide 1. EMS Run Report

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Section: HSVI/ED -Resus/ED Discharge Disposition

POST ED DISCHARGE DISPOSITION Definition The disposition unit the order was written for the patient to be discharged to, from the ED. Element Values 3. Operating Room 4. Intensive Care Unit 5. Step Down Unit 6. Floor 7. Telemetry Unit 8. Observation Unit 9. Burn Unit 13. Labor and Delivery 14. Nenonatal/Pediatric Care Unit 16. Interventional Radiology 40. Home or Self Care (Routine Discharge) 41. Home with Services 42. Left AMA 43. Correctional Facility/Court/Law Enforcement 44. Morgue 45. Child Protective Agency 70. Acute Care Facility 71. Intermediate Care Facility 72. Skilled Nursing Facility

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Section: HSVI/ED -Resus/ED Discharge Disposition 73. Rehab (Inpatient) 74. Long- Term Care 75. Hospice 76. Mental Health/Psychiatric Hospital (Inpatient) 77. Nursing Home 79. Another Type of Inpatient Facility Not Defined Elsewhere 80. Burn Center /. Not Applicable ?. Unknown Additional Information

• The null value “Not Applicable” is reported if the patient was directly admitted to the hospital.

• If ED Discharge Disposition is Home with Services; Morgue; Jail (Correctional Facility),Institutional Care (Intermediate Care Facility), Mental Health; Home without Services; Left AMA; or Transferred to another hospital, then Hospital Discharge Date, Hospital Discharge Time, and Hospital Discharge Disposition must be “Not Applicable”.

• If multiple orders were written, report the final disposition order. Data Source Hierarchy Guide 1. Physician Order 2. Discharge Summary 3. Nursing Notes/Flow Sheet 4. Case Management/Social Services Notes 5. ED Record 6. History & Physical Associated Edit Checks Rule ID Level Message 6101 1 Value is not a valid menu option 6102 2 Element cannot be blank 6104 2 Element cannot be “Not Known/Not Recorded” 6140 1 Single Entry Max exceeded

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Section: HSVI/ED -Resus/Respiration Assisted

INITIAL ED/HOSPITAL RESPIRATORY ASSISTANCE Definition Determination of respiratory assistance associated with the initial ED/hospital respiratory rate within 30 minutes or less of ED/hospital arrival. Element Values Y. Yes N. No NA. Not Applicable UKN. Unknown Data Source Hierarchy Guide 1. Triage/Trauma/Hospital Flow Sheet 2. Nurses Notes/Flow Sheet 3. Respiratory Therapy Notes/Flow Sheet Associated Edit Checks Rule ID Level Message 5101 1 Value is not a valid menu option 5102 2 Element cannot be blank

5103 2 Element must be “Not Applicable” when Initial ED/Hospital Respiratory Rate is “Not Known/Not Recorded” 5140 1 Single Entry Max exceeded

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Section: HSVI/ED -Resus/Respiration Assisted/Method

INITIAL ED/HOSPITAL RESPIRATORY ASSISTANCE: RESPIRATION ASSISTED TYPE Definition The device used to assist the patient’s respirations. NOTE: Will only populate if you answer yes. Element Values 1. Bag Value Mask 2. Nasal Airway 3. Oral Airway 4. Ventilator ?. Unknown Data Source Hierarchy Guide 1. History and Physical 2. Flowsheets 3. Progress Notes Note: Field is only active if “Respirations Assisted” is marked “Y”

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Section: HSVI/ED -Resus/Initial Systolic Blood Pressure

INITIAL ED/HOSPITAL SYSTOLIC BLOOD PRESSURE Definition First recorded systolic blood pressure in the ED/hospital within 30 minutes or less of ED/hospital arrival. Element Values • Relevant value for data element Additional Information • Please note that first recorded hospital vitals do not need to be from the same assessment. • Measurement reported must be without the assistance of CPR or any type of mechanical chest compression device. For those patients who are receiving CPR or any type of mechanical chest compressions, report the value obtained while compressions are paused. Data Source Hierarchy Guide 1. Triage/Trauma/Hospital Flow Sheet 3. Physician Notes 2. Nurses Notes/Flow Sheet 4. History & Physical Associated Edit Checks Rule ID Level Message 4701 1 Invalid value 4702 2 Element cannot be blank 4704 3 The value is above 220 4705 2 Element cannot be “Not Applicable” 4706 2 The value submitted falls outside the valid range of 0-380 4707 3 The value is below 30 4740 1 Single Entry Max exceeded

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Section: HSVI/ED -Resus/Initial Diastolic Blood Pressure

INITIAL ED/HOSPITAL DIASTOLIC BLOOD PRESSURE Definition First recorded diastolic blood pressure in the ED/Hospital within 30 minutes or less of ED/Hospital arrival. Element Values • Relevant value for data element Note: The first recorded hospital vitals do not need to be from the same assessment. Measurement reported must be without the assistance of CPR or any type of mechanical chest compression device. For those patients who are receiving CPR or any type of mechanical chest compressions, report the value obtained while compressions are paused. Data Source Hierarchy Guide 1. Flowsheets 2. ED Trauma Summary 3. History and Physical 4. Progress Notes

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Section: HSVI/ED -Resus/Initial Pulse Rate

INITIAL ED/HOSPITAL PULSE RATE Missing Element in HSVI Registry Definition First recorded pulse in the ED/hospital (palpated or auscultated) within 30 minutes or less of ED/hospital arrival (expressed as a number per minute). Element Values • Relevant value for data element Additional Information • Please note that first recorded hospital vitals do not need to be from the same assessment. • Measurement reported must be without the assistance of CPR or any type of mechanical chest compression device. For those patients who are receiving CPR or any type of mechanical chest compressions, report the value obtained while compressions are paused. Data Source Hierarchy Guide 1. Triage/Trauma/Hospital Flow Sheet 2. Nurses Notes/Flow Sheet Associated Edit Checks Rule ID Level Message 4801 1 Invalid value 4802 2 Element cannot be blank 4804 3 The value is above 220 4805 2 Element cannot be “Not Applicable” 4806 2 The value submitted falls outside the valid range of 0-300 4807 3 The value is below 30 4840 1 Single Entry Max exceeded

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Section: HSVI/ED -Resus/Unassisted Resp Rate

INITIAL ED/HOSPITAL RESPIRATORY RATE Definition First recorded respiratory rate in the ED/hospital within 30 minutes or less of ED/hospital arrival (expressed as a number per minute). Element Values • Relevant value for data element Additional Information • If reported, report additional data element: Initial ED/Hospital Respiratory Assistance. • Please note that first recorded hospital vitals do not need to be from the same assessment. Data Source Hierarchy Guide 1. Triage/Trauma/Hospital Flow Sheet 2. Nurses Notes/Flow Sheet 3. Respiratory Therapy Notes/Flow Sheet Associated Edit Checks Rule ID Level Message 5001 1 Invalid value. 5002 2 Element cannot be blank 5005 2 The value submitted falls outside the valid range of 0-100 5006 2 Element cannot be “Not Applicable” 5007 3 The value is below 5 5008 3 The value is above 75 5040 1 Single Entry Max exceeded

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Section: HSVI/ED -Resus/Initial Assisted Resp Rate

INITIAL ED/HOSPITAL RESPIRATORY ASSISTANCE RATE Definition If “Reparation Assisted” is marked “Y” for Yes, then document the assisted respiratory rate per minute Element Values Numerical value for assisted respiratory rate per minute Additional Information • Only reported if Initial ED/Hospital Respiration Assisted is reported Yes. • Respiratory assistance is defined as mechanical and/or external support of respiration. • Please note that first recorded hospital vitals do not need to be from the same assessment. Data Source Hierarchy Guide 1. Triage/Trauma/Hospital Flow Sheet 2. Nurses Notes/Flow Sheet 3. Respiratory Therapy Notes/Flow Sheet Associated Edit Checks Rule ID Level Message 5101 1 Value is not a valid menu option 5102 2 Element cannot be blank 5140 1 Single Entry Max exceeded

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Section: HSVI/ED -Resus/GCS EYE

INITIAL ED/HOSPITAL GCS - EYE Definition First recorded Glasgow Coma Score (Eye) in the ED/hospital within 30 minutes or less of ED/hospital arrival. Element Values 1. No eye movement when assessed 2. Opens eyes in response to painful stimulation 3. Opens eyes in response to verbal stimulation 4. Opens eyes spontaneously /. Not Applicable ?. Unknown Additional Information • If a patient does not have a numeric GCS score recorded, but written documentation closely (or directly) relates to verbiage describing a specific level of functioning within the GCS scale, the appropriate numeric score may be reported. E.g. the chart indicates: "patient's pupils are PERRL," an Eye GCS of 4 may be reported, IF there is no other contradicting documentation. • Please note that first recorded hospital vitals do not need to be from the same assessment. • The null value “Not Known/Not Recorded” is reported if Initial ED/Hospital GCS 40 – Eye is documented. • The null value “Not Known/Not Recorded” is reported if the patient’s Initial ED/Hospital GCS - Eye was not measured within 30 minutes or less of ED/hospital arrival. Data Source Hierarchy Guide 1. Triage/Trauma/Hospital Flow Sheet 2. Nurses Notes/Flow Sheet 3. Physician Notes/Flow Sheet

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Section: HSVI/ED -Resus/GCS EYE Associated Edit Checks Rule ID Level Message 5401 1 Value is not a valid menu option 5403 2 Element cannot be blank 5404 2 Element cannot be “Not Applicable” 5405 2 Element must be “Not Known/Not Recorded” when Initial ED/Hospital GCS 40 – Eye is reported. 5440 1 Single Entry Max exceeded

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Section: HSVI/ED -Resus/GCS VERBAL

INITIAL ED/HOSPITAL GCS - VERBAL Definition First recorded Glasgow Coma Score (Verbal) within 30 minutes or less of ED/hospital arrival. Element Values Pediatric (≤ 2 years):

1. No vocal response 5. Smiles, oriented to sounds, follows objects, interacts 2. Inconsolable, agitated /. Not Applicable 3. Inconsistently consolable, moaning ?. Unknown 4. Cries but is consolable, inappropriate interactions

Adult 1. No verbal response 5. Oriented 2. Incomprehensible sounds /. Not Applicable 3. Inappropriate words ?. Unknown 4. Confused

Additional Information • If patient is intubated, then the GCS Verbal score is equal to 1. • If a patient does not have a numeric GCS score recorded, but written documentation closely (or directly) relates to verbiage describing a specific level of functioning within the GCS scale, the appropriate numeric score may be reported. E.g. the chart indicates: "patient is oriented to person place and time," a Verbal GCS of 5 may be reported, IF there is no other contradicting documentation. • Please note that first recorded hospital vitals do not need to be from the same assessment. • The null value “Not Known/Not Recorded” is reported if Initial ED/Hospital GCS 40 – Verbal is reported. • The null value “Not Known/Not Recorded” is reported if the patient’s Initial ED/Hospital GCS – Verbal was not measured within 30 minutes or less of ED/Hospital arrival.

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Section: HSVI/ED -Resus/GCS VERBAL Data Source Hierarchy Guide 1. Triage/Trauma/Hospital Flow Sheet 2. Nurses Notes/Flow Sheet 3. Physician Notes/Flow Sheet Associated Edit Checks Rule ID Level Message 5501 1 Value is not a valid menu option 5503 2 Element cannot be blank 5504 2 Element cannot be “Not Applicable” 5505 2 Element must be “Not Known/Not Recorded” when Initial ED/Hospital GCS 40 – Verbal is reported. 5540 1 Single Entry Max exceeded

83

Section: HSVI/ED -Resus/GCS MOTOR

INITIAL ED/HOSPITAL GCS - MOTOR Definition First recorded Glasgow Coma Score (Motor) within 30 minutes or less of ED/hospital arrival. Element Values Pediatric (≤ 2 years):

1. No motor response 4. Withdrawal from pain /. Not Applicable 2. Extension to pain 5. Localizing pain ?. Unknown 3. Flexion to pain 6. Appropriate response to stimulation

Adult 1. No motor response 4. Withdrawal from pain /. Not Applicable 2. Extension to pain 5. Localizing pain ?. Unknown 3. Flexion to pain 6. Obeys commands

Additional Information • If a patient does not have a numeric GCS score recorded, but written documentation closely (or directly) relates to verbiage describing a specific level of functioning within the GCS scale, the appropriate numeric score may be reported. E.g. the chart indicates: "patient withdraws from a painful stimulus," a Motor GCS of 4 may be reported, IF there is no other contradicting documentation. • Please note that first recorded/hospital vitals do not need to be from the same assessment. • The null value “Not Known/Not Recorded” is reported if Initial ED/Hospital GCS 40 – Motor is reported. • The null value “Not Known/Not Recorded” is reported if the patient’s Initial ED/Hospital GCS – Motor was not measured within 30 minutes or less of ED/Hospital arrival.

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Section: HSVI/ED -Resus/GCS MOTOR Data Source Hierarchy Guide 1. Triage/Trauma/Hospital Flow Sheet 2. Nurses Notes/Flow Sheet 3. Physician Notes/Flow Sheet Associated Edit Checks Rule ID Level Message 5601 1 Value is not a valid menu option 5603 2 Element cannot be blank 5604 2 Element cannot be “Not Applicable” 5605 2 Element must be “Not Known/Not Recorded” when Initial ED/Hospital GCS 40 – Motor is reported 5640 1 Single Entry Max exceeded

85

Section: HSVI/ED -Resus/Alcohol Screen

ALCOHOL SCREEN Definition A blood alcohol concentration (BAC) test was performed on the patient within 24 hours after first hospital encounter. Element Values 1. No (Not Tested) 2. No (Confirmed by Test) 3. Yes (Confirmed by Test [Trace Levels]) 4. Yes (Confirmed by Test [Beyond Legal Limit]) /. Not Applicable ?. Unknown Additional Information • Alcohol screen may be administered at any facility, unit, or setting treating this patient event. Data Source Hierarchy Guide 1. Lab Results – Note how reported in lab results as mg/dL or g/dL. Registry collects mg/dL 2. Transferring Facility Records Associated Edit Checks Rule ID Level Message 5911 1 Value is not a valid menu option 5912 2 Element cannot be blank 5913 2 Element cannot be “Not Applicable” 5940 1 Single Entry Max exceeded

86

Section: HSVI/ED -Resus/Drug Use Indicators

DRUG SCREEN Definition First recorded positive drug screen results within 24 hours after first hospital encounter (select all that apply). Element Values 1. No (Not Tested) 2. No (Confirmed by Test) 3. Yes (Confirmed by Test [Trace Levels]) 4. Yes (Confirmed by Test [Beyond Legal Limit]) /. Not Applicable ?. Unknown Additional Information • Report positive drug screen results within 24 hours after first hospital encounter, at either your facility or the transferring facility. • "None" is reported for patients whose only positive results are due to drugs administered at any facility (or setting) treating this patient event, or for patients who were tested and had no positive results. • If multiple drugs are detected, only report drugs that were NOT administered at any facility (or setting) treating this patient event. Mark Clinician Administered “Y” if medication given as part of patient treatment for this event.

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Section: HSVI/ED -Resus/Drug Use Indicators Data Source Hierarchy Guide 1. Lab Results 2. Transferring Facility Records Associated Edit Checks Rule ID Level Message 6011 1 Value is not a valid menu option 6012 2 Element cannot be blank 6013 2 Element cannot be “Not Applicable” 6014 2 Element cannot be “Not Known/Not Recorded” along with any other valid value 6050 1 Multiple Entry Max exceeded

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Section: HSVI/Diagnosis – Injury Coding/ICD 10 Injury Codes There are two different ways to code diagnosis codes in the trauma registry.

1. One is the Tri-Code feature where the narrative information is typed into the box and the computer will assign ICD-10 and AIS codes. These codes need to be checked after they populate to ensure that they are accurate and meet the AIS coding rules.

2. The second way is to enter the AIS codes and then have them converted to ICD -10 codes. These codes need to be checked as well because AIS is not as comprehensive as the ICD-10 system.

Please refer to the training video for more information on using the ESO Registry features.

Tri code narrative ICD-10 INJURY DIAGNOSES Definition Diagnoses related to all identified injuries. Element Values • Injury diagnoses as defined by ICD-10-CM code range S00-S99, T07, T14, T20-T28 and T30- T32. • The maximum number of diagnoses that may be reported for an individual patient is 50. Additional Information • ICD-10-CM codes pertaining to other medical conditions (e.g., CVA, MI, co-morbidities, etc.) may also be included in this element.

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Section: HSVI/Diagnosis – Injury Coding/ICD 10 Injury Codes Data Source Hierarchy Guide 1. Autopsy/Medical Examiner Report 2. Operative Reports 3. Radiology Reports 4. Physician's Notes 5. Trauma Flow Sheet 6. History & Physical 7. Nursing Notes/Flow Sheet 8. Progress Notes 9. Discharge Summary Associated Edit Checks Rule ID Level Message 8701 1 Invalid value (ICD-10-CM only) 8702 2 Element cannot be blank 8703 2 At least one diagnosis must be provided and meet inclusion criteria. (ICD-10-CM only) 8705 1 Invalid value (ICD-10-CA only) 8706 2 At least one diagnosis must be provided and meet inclusion criteria. (ICD-10-CA only) 8750 1 Multiple Entry Max exceeded ICD 10 Coding

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Section: HSVI/Diagnosis – Injury Coding/ICD 10 Injury Codes ICD 10 Coding

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Section: HSVI/Diagnosis – Injury Coding/ICD 10 Injury Codes ICD 10 Coding

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Section: HSVI/Diagnosis – Injury Coding/ICD 10 Injury Codes/Non-Trauma Diagnosis Non-Trauma Diagnosis Definition All other HSVI inclusions that do not have a trauma diagnosis. Element Values • Relevant Data for Element Value Data Source Hierarchy Guide 1. Progress Notes 2. Nursing Notes 3. Consult Notes 4. History and Physical 5. Radiology Reports 6. Autopsy Reports 7. Lab Values *See below for coding instructions

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Section: HSVI/Diagnosis – Injury Coding/ICD 10 Injury Codes/Non-Trauma Diagnosis

HSVI Data Entry for Sexual Assault or other non-injury ICD codes Complete the record as usual under the “HSVI” tab. Code the “Injury” “Mechanism of Injury” coding as described in the video.

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Section: HSVI/Diagnosis – Injury Coding/ICD 10 Injury Codes/Non-Trauma Diagnosis Under the “HSVI” Tab “Diagnosis - Injury Coding” with no injury diagnosis enter the information as follows:

In the “Narrative” box just below the “Tri-Code ICD 10” type in “No Injury”

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Section: HSVI/Diagnosis – Injury Coding/ICD 10 Injury Codes/Non-Trauma Diagnosis When you use the “Check” button, it will show the following errors:

To clear the errors, select each error and click the “Validate” button in the “Check” box summary.

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Section: HSVI/Diagnosis – Injury Coding/ICD 10 Injury Codes/Non-Trauma Diagnosis When you select the “Validate” button, the system will ask if you want to validate the item, select “OK” for each error and the record will complete.

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Section: HSVI/Outcome/Initial Discharge/Discharge Date

HOSPITAL DISCHARGE DATE Definition The date the order was written for the patient to be discharged from the hospital. Element Values • Relevant value for data element Additional Information • Reported as MM-DD-YYYY. • The null value “Not Applicable” is reported if ED Discharge Disposition = 40, 42, 43, 44, or 73. • If Hospital Discharge Disposition is “5. Deceased/Expired,” then Hospital Discharge Date is the date of death as indicated on the patient’s death certificate. Data Source Hierarchy Guide 1. Physician Order 4. Case Management/Social Services Notes 2. Discharge Instructions 5. Discharge Summary 3. Nursing Notes/Flow Sheet Associated Edit Checks Rule ID Level Message 7701 1 Date is not valid 7702 1 Date out of range 7703 2 Element cannot be blank 7704 3 Hospital Discharge Date is earlier than EMS Dispatch Date 7705 3 Hospital Discharge Date is earlier than EMS Unit Arrival on Scene Date 7706 3 Hospital Discharge Date is earlier then EMS Unit Scene Departure Date

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Section: HSVI/Outcome/Initial Discharge/Discharge Date 7707 2 Hospital Discharge Date is earlier than ED/Hospital Arrival Date 7708 2 Hospital Discharge Date is earlier than ED Discharge Date 7709 2 Hospital Discharge Date is earlier than Date of Birth 7710 3 Hospital Discharge Date minus Injury Incident Date is greater than 365 days 7711 3 Hospital Discharge Date minus ED/Hospital Arrival Date is greater than 365 days 7712 2 Element must be and can only be "Not Applicable" when ED Discharge Disposition is 40, 42, 43, 44, or 73. 7740 1 Single Entry Max exceeded

99

Section: HSVI/Outcome/Initial Discharge/Discharge Time

HOSPITAL DISCHARGE TIME Definition The time the order was written for the patient to be discharged from the hospital. Element Values • Relevant value for data element Additional Information • Reported as HH:MM military time. • The null value “Not Applicable” is reported if ED Discharge Disposition = 40, 42, 43, 44, or 73. • If Hospital Discharge Disposition is “5. Deceased/Expired,” then Hospital Discharge Time is the time of death as indicated on the patient’s death certificate. Data Source Hierarchy Guide 1. Physician Order 4. Case Management/Social Services Notes 2. Discharge Instructions 5. Discharge Summary 3. Nursing Notes/Flow Sheet Associated Edit Checks Rule ID Level Message 7801 1 Time is not valid 7802 1 Time out of range 7803 2 Element cannot be blank 7804 3 Hospital Discharge Time is earlier than EMS Dispatch Time 7805 3 Hospital Discharge Time is earlier than EMS Unit Arrival on Scene Time 7806 3 Hospital Discharge Time is earlier than EMS Unit Scene Departure Time 7807 2 Hospital Discharge Time is earlier than ED/Hospital Arrival Time

100

Section: HSVI/Outcome/Initial Discharge/Discharge Time 7808 2 Hospital Discharge Time is earlier than ED Discharge Time 7809 2 Element must be and can only be “Not Applicable” when ED Discharge Disposition is 40, 42, 43, 44, or 73. 7840 1 Single Entry Max exceeded

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Section: HSVI/Outcome/Initial Discharge/Discharged To

HOSPITAL DISCHARGE DISPOSITION The disposition of the patient when discharged from the hospital. Element Values 40. Discharged to home or self-care (routine discharge) 41. Discharged/Transferred to home under care of organized home health service 42. Left AMA 43. Discharged/Transferred to court/law enforcement. 44. Deceased/Expired 45. Child Protective Agency 70. Discharged/Transferred to a short-term general hospital for inpatient care 71. Discharged/Transferred to an Intermediate Care Facility (ICF) 72. Discharged/Transferred to Skilled Nursing Facility (SNF) 73. Discharged/Transferred to inpatient rehab or designated unit 74. Discharged/Transferred to Long Term Care Hospital (LTCH) 75. Discharged/Transferred to hospice care 76. Discharged/Transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital 77. Nursing Home 79. Discharged/Transferred to another type of institution not defined elsewhere 80. Burn Center ?. Unknown

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Section: HSVI/Outcome/Initial Discharge/Discharged To Additional Information Element value “40. Home" refers to the patient's current place of residence (e.g., Prison, Child Protective Services etc.). Element values based upon UB-04 disposition coding. Disposition to any other non-medical facility should be coded as 40. Disposition to any other medical facility should be reported as 79. The null value "Not Applicable" is reported if ED Discharge Disposition = 40, 42, 43, 44, or 73. Hospital Discharge Dispositions which were retired greater than 2 years before the current NTDS version are no longer listed under Element Values above, which is why there are numbering gaps. Refer to the NTDS Change Log for a full list of retired Hospital Discharge Dispositions. If multiple orders were written, report the final disposition order. Data Source Hierarchy Guide 1. Physician Order 2. Discharge Instructions 3. Nursing Notes/Flow Sheet 4. Case Management/Social Services Notes 5. Discharge Summary Associated Edit Checks Rule ID Level Message 7901 1 Value is not a valid menu option 7902 2 Element cannot be blank 7907 2 Element must be “Not Applicable” when ED Discharge Disposition is 40, 42, 43, 44, or 73. 7908 2 Element cannot be “Not Applicable” if ED Discharge Disposition is not 40, 42, 43, 44, or 73. 7909 2 Element cannot be “Not Known/Not Recorded” when Hospital Arrival Date and Hospital Discharge Date are not “Not Applicable” or "Not Known/Not Recorded” 7940 1 Single Entry Max exceeded Note: “/ - Not Applicable” is missing from the IDPH ESO Web Registry. Rule ID 7907 and 7908 indicate the correct response is “/ - Not Applicable” for certain ED Discharge Dispositions. Until this can be corrected, use the same response in the “Outcome – Discharged to” as is in the ED Discharge Disposion.

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Section: HSVI/Outcome/Initial Discharge/Discharge Alternate Caregiver

DISCHARGE TO ALTERNATE CAREGIVER Definition Was the patient discharged with a different person than the person that primarily cares for them or lives with them? NOTE: Will only populate if there is a Y (yes) in the report of physical abuse in the Injury Section Element Values Y = Yes N = No NA = Not Applicable UNK = Unknown Data Source Hierarchy Guide 1. Discharge Summary 2. Child Abuse Physician Notes 3. Case Management Notes 4. Child Protective Service Notes 5. Nursing Notes

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Section: HSVI/Outcome/Initial Discharge/Discharge/Transferred To Facility

105

Section: HSVI/Outcome/Initial Discharge/Discharge/Transferred To Facility IF TRANSFERRED, FACILITY Definition The facility that the patient was transferred to, if the patient was transferred out of your hospital. Element Values • Relevant Value for Data Element Data Source Hierarchy Guide 1. Discharge Summary 2. Case Management Notes 3. Progress Notes 4. Nursing Notes

106

Section: HSVI/Outcome/Billing/Charges Billed

CHARGES BILLED $ Definition The total charges billed to the patient for their hospital stay. Element Value • Relevant Value for Data Element Data Source Hierarchy Guide 1. Billing/Coding 2. Medical Records

107

Section: HSVI/Outcome/Billing/ICD 10 DRG

ICD-10 DRG Definition The diagnosis related group which is how hospitalization costs are calculated through Medicare. Element Value • Relevant Value for Data Element Data Source Hierarchy Guide 1. Billing/Coding 2. Medical Records

108

Section: HSVI/Outcome/Billing/Primary Payor

PRIMARY PAYOR Definition The primary payor responsible for paying for the hospitalization costs. Note: Organ Donor Payor: Per NDTS, Primary Payor = payor source at admission; NOT the organ procurement agency. Element Value 1. Self-Pay 11. Other Commercial 2. HMO 12. Other Government 3. PPO 13. Not Billed for Any Reason 5. Blue Cross Blue Shield (including PPO and HMO, etc.) 14. Charity 6. Automobile 15. Other (Violence fund) 7. Worker’s Compensation 16. Charity Pending 8. Medicare 17. Liability 9. Medicaid /. Not Applicable 10. Military (Tricare) ?. Unknown Data Source Hierarchy Guide 1. Billing/Coding 2. Medical Records

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Section: HSVI/Outcome/Billing/Primary Payor Fees Collected

PRIMARY PAYOR AMOUNT $ Definition The total amount of payment collected from the Primary Payor. Element Value • Relevant Value for Data Element Data Source Hierarchy Guide 1. Billing/Coding 2. Medical Records

110

Section: HSVI/Outcome/Billing/Primary Payor Date Paid

PRIMARY PAYOR DATE Definition The last date the primary payor made payments for the hospitalization. Element Value • Relevant Value for Data Element Data Source Hierarchy Guide 1. Billing/Coding 2. Medical Records

111

Section: HSVI/Outcome/Billing/Additional Payors

ADDITIONAL PAYORS Definition Secondary payors responsible for paying some of the hospital costs after the primary payor. Element Value 1. Self-Pay 2. HMO 3. PPO 5. Blue Cross Blue Shield 6. Automobile 7. Worker’s Compensation 8. Medicare 9. Medicaid 10. Military (Tricare) 11. Other Commercial 12. Other Government 13. Not Billed for Any Reason 14. Charity 15. Other 16. Charity Pending 17. Liability /. Not Applicable ?. Unknown

112

Section: HSVI/Outcome/Billing/Additional Payors Data Source Hierarchy Guide 1. Billing/Coding 2. Medical Records

113

Section: HSVI/Outcome/Billing/Additional Payors Fees Collected

ADDITIONAL PAYOR AMOUNT $ Definition The total amount of payment collected from the additional payor. Element Value • Relevant Value for Data Element Data Source Hierarchy Guide 1. Billing/Coding 2. Medical Records

114

Section: HSVI/Outcome/Billing/Additional Payors Date Collected

ADDITIONAL PAYOR DATE Definition The last date the primary payor made payments for the hospitalization. Element Value • Relevant Value for Data Element Data Source Hierarchy Guide 1. Billing/Coding 2. Medical Records